Northumberland Recovery College Referral

Title: *

First name: *

Last name: *

Date of Birth: *

Gender Identity: *

Is Gender Identity the same as Gender Assigned at Birth? *

Yes

No

What are you preferred pronouns?

Do you live or work in Northumberland

NHS Number:

Ethnicity: *

No fixed abode

Address (House or building name): *

House Number/Street:

Town: *

County: *

Home postcode: *

Can we write to you at this address?

Yes

No

Accommodation Type: *

Is the person residing in the accommodation specified above?

Yes

No

If no, where are they residing?

In the section below, please give the preferred contact details of the person you're referring, alongside any relevant supporting information:

Email address:*

Can we email you at this address?

Yes

No

Planned discharge destination:

Section 117:

Is this person subject to section 117 aftercare under the mental health act?

Yes

No

Out of Area:

Would this person be deemed as an 'out of area' referral? (i.e. they are not registered as a resident within the local authorty area where the service you want them to access is based)

Yes

No

Consent

Do you consent to Everyturn Mental Health Involvement? We are unable to process the referral without your consent.

Yes

No

We are unable to continue referral without consent.

Risks in relation to initial assessment/visit

Are there any risk to us visiting the person where they currently reside? If yes, please state: *

Are there any issues in accessing the property where the person currently resides? If yes, please state. *

Additional details that may support the referral can be listed below:

Next of kin details

Relationship to the person being referred:

Given name

Address

Telephone Number

Email

Permission to contact Next of Kin?

Yes

No

Additional discharge details:

Risk and safety

Please tell us about any known risks relating to the person, including any risks of harm to others, including staff. Recent risk assessments are helpful if available.*

Please tell us about any known risks relating to the person.

Risk of suicide/self-harm

Risk to staff

Risk to others

Lifestyle-related risks

No risk

Other (detail below)

Please could you provide some extra information

Recent contact with services

Please tell us about any recent contacts with services you have had (e.g. Crisis Team, Ambulance service, Police, GP).

Other relevant professions involved

If phone call or text within 24 hours is not suitable for service user, please provide alternative contact details, including method, named contact etc (optional)

Best time to contact

Further Information (Reasons for referral)

Please include details of the presenting problem in relation to distress (e.g. self-harm, low mood, distress etc)

Please include details of any known contributing factors, such as alcohol; relationship problems; finances; employment issues; housing etc., and how the DBI service can support.

Are there any known risks to self, (e.g., suicidal thoughts, self-harm etc.,) risk from others (e.g., physical, sexual, emotional etc.,) or related to substance use?

Response to ‘distress rating question’. Ask the service user to think about when their distress was at its worst today. How would they rate their level of distress at that time, when 0 is no distress and 10 is extreme distress?.

Was the service user under the influence of alcohol or other substances at the time of referral?

Has the information sheet been given to the service user?

Yes

No

Risk to others (to be completed by referrer)

If this service user is known to be violent and it is likely that the safety of the level two provider will be compromised, please provide relevant information.

Is the person a carer for anyone?

Yes

No

Does the person have a cognitive impairment that may impact ability to make decisions?

Yes

No

Key people involved: Social Worker/Care Coordinator

First Name :

Last Name :

Team :

Address:

Contact Number :

Email Address :

Does the person have any disabilities (please select all that apply)

Mental Health Needs

Physical Disability

Learning Disability

Autism Spectrum

Data Protection Act

Because of the Data Protection Act we need your agreement to for us to securely hold any personal information (including the information on this form), on a computer and in a filing system. It is our policy that all personal data will be held in accordance with the principles and requirements of Data Protection and other relevant legislation, and that procedures will be put in place to ensure the fair processing of data relating to individuals.

Please indicate agreement has been given for chain reaction to securely hold the information on this form by selecting the check box.

Yes